Application For Employee Refund Of Occupational Taxes Withheld - Louisville/jefferson County Metro Revenue Commission

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LOUISVILLE/JEFFERSON COUNTY
METRO REVENUE COMMISSION
APPLICATION FOR EMPLOYEE REFUND OF OCCUPATIONAL TAXES WITHHELD
PART I: EMPLOYER INFORMATION – (Please print)
Employer’s Name:
Employer’s Federal ID Number:
Employer’s Louisville/Jefferson County Metro Revenue Commission Account Number: ___________________________
W-2 FORM MUST BE SUBMITTED WITH APPLICATION OR A DELAY WILL OCCUR.
PART II: APPLICANT INFORMATION - This section must be completed by all employees. (Please print)
Refund Requested for Year:
Employee’s SSN:
Employee’s Name:
Daytime Phone No:
Street Address (include City, State & Zip code):
Employee’s Job Description:
PART III: This section must be completed by employees requesting a refund for work performed outside
Louisville Metro, Kentucky. If all work was performed in Louisville Metro, Kentucky, skip to Part IV.
th
Quarters Involved in Overpayment
1st
2nd
3rd
4
(Check applicable quarters)
Jan-March
April-June
July-Sept
Oct-Dec
Line 1 ____________ Number of Hours worked outside Louisville Metro, Kentucky
Line 2 ____________ Total Number of Hours worked (excluding Holiday, vacation, and sick days) [Normal work year = 2,080 hours]
Line 3 ____________ Percentage of time worked outside Louisville Metro, Kentucky (Divide Line 1 by Line 2)
Note: Must be at least 5% to claim refund – (See instructions) If less than 5%, do not complete this form.
Line 4 $____________ Total gross wages (including deferred compensation) per W-2 Form (Medicare or Local Wage line)
0.00
Line 5 $____________ Total wages earned outside Louisville Metro, Kentucky (Multiply Line 3 by Line 4)
Line 6 $____________ Local Taxable Wages (Subtract Line 4 from Line 5)
Line 7 $____________ Occupational Tax Due (Multiply Line 6 by applicable tax rate, 1.45% for non-resident or 2.2% for resident)
Line 8 $____________ Amount of tax withheld per W-2 Form for prior year or year to date payroll check stub for current year
(Copy of applicable document must be submitted with application.)
Line 9 $____________ Amount of Refund Requested (Subtract Line 7 from Line 8)
MAILING ADDRESS: P.O. BOX 35410 • LOUISVILLE, KENTUCKY 40232-5410
Telephone: (502) 574-4860 •
• Fax: (502) 574-4818 • • TDD: (502) 574-4811

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